State investigators probing the hardest-hit New York nursing homes have targeted The Hurlbut, the troubled Brighton facility where at least 17 residents have died with COVID-19.


Inspectors from the state Department of Health visited the nursing home in late April and cited the facility at least once for placing residents in immediate jeopardy; by not segregating infected and presumptively uninfected residents. Immediate jeopardy citations, the most serious category of violation, are rare and only given where serious injury or death has occurred or is likely to occur, and where immediate action is required.


The nursing home quickly corrected the problem and the citation was withdrawn within hours, according to the facility's owner, Hurlbut Care Communities. The company's statement blamed recently changed state rules for the serious citation.


Hurlbut said health inspectors also had visited Hornell Gardens in Steuben County and the Brightonian nursing home in Brighton. At least nine people have died at Hornell Gardens, and the Brightonian has had an unpublicized outbreak of COVID-19 cases.


"Each facility passed the survey. The state (health) inspectors complimented us," Hurlbut Care Communities asserted in its statement.


Results of the inspections have not yet been posted publicly by the state health department. A department spokesman, Gary Holmes, declined to comment on The Hurlbut, saying only that the department was making unannounced inspections to investigate COVID-related concerns at nursing homes statewide.


Investigators for the state Attorney General's office, meanwhile, interviewed relatives of Hurlbut residents last week, the Democrat and Chronicle can confirm.


Family members reported they were asked whether Hurlbut disclosed the extent of coronavirus infections there and fully informed them of their loved ones' COVID-19 diagnoses. One relative said an investigator also asked about end-of-life care and the use of morphine.


In its statement, Hurlbut said it had not been contacted by the Attorney General's office, and said it adhered to all state and federal guidelines regarding communication with families.


Targeted investigations of New York nursing homes were launched after a wave of publicity about mass deaths in facilities across the state.


Gov. Andrew Cuomo and Attorney General Letitia James announced the coordinated investigations on April 23, saying the agencies would focus on homes suspected of failing to comply with family-notification policies and safety directives.


Cuomo threatened offenders with steep fines and possible closure.


The Hurlbut had already been singled out by Monroe County's public health commissioner, Dr. Michael Mendoza, who on April 21 asked state officials to determine the true scope of COVID-19 cases and deaths at the home.


Mendoza cited an April 20 Democrat and Chronicle story that exposed at least eight deaths, widespread infections and complaints about a lack of communication at the home, which is located off East Henrietta Road across from Monroe Community College.


Since that story was published, the D&C has learned from family members that at least nine additional residents of The Hurlbut have died after being infected with the coronavirus. Relatives of two other residents say they're awaiting confirmation that their loved ones died of COVID-19 as well.


Family members say they've been told that numerous employees have been infected as well.


Some of the deaths came with little or no forewarning.


Relatives of Daniel Hall Blake, who had lived at The Hurlbut for eight years, learned on April 17 that he had fallen ill. He died just a few hours later, according to his granddaughter, Andrea Roman.


His remains had been taken to a funeral home before the family found out, she said.


Blake had not been tested for coronarivus, but his death certificate listed COVID-19.


Roman said she spoke twice with an Attorney General’s investigator, and was asked if the nursing home had set up a hospice plan for her grandfather or had given him painkillers such as morphine. She told them that had not happened.


Her complaint is about something else that did not happen. "I feel like as soon as somebody is sick or having any kind of symptoms, the family should be informed," Roman said. "It blows my mind how fast it was. What they were telling our family was he got sick on Thursday and died on Friday."


Conflicting numbers


Hurlbut is hardly alone. The latest figures posted by the state health department indicate 3,087 nursing home residents had died through Friday. Another 646 residents of other elder-care facilities had died as well.


County-by-county figures were first published April 13 after a bevy of unflattering news stories about a lack of transparency on the part of state officials and nursing home owners alike. On April 17, the state also began to publish facility-by-facility totals.


But the numbers remains inaccurate and incomplete. Only homes with five or more deaths among its residents are listed, and there are many omissions.


Kirkhaven in Rochester, which has acknowledged 14 confirmed COVID-19 deaths, is not on the state list. Neither are The Hurlbut or Hornell Gardens.


St. John's Home in Rochester reported 11 resident deaths. It is is the only facility in Monroe County on the list and one of the few in upstate New York.


Holmes, the state health department spokesman, said "the unprecedented amount and specificity of data we are providing to the public will continue to evolve."


Hurlbut Care Communities has said that it reported all deaths at its nursing homes to the state as required.


In addition to the fatalities at The Hurlbut and Hornell Gardens, four residents have died at the company's Avon Nursing & Rehabilitation, according to data posted by Livingston County.


Two New York state Assembly members have called for an investigation into COVID-19 at the Avon nursing home.


The company also said on Friday it was working to comply with an April 16 executive order from Cuomo that nursing homes inform residents and families of all COVID-19 diagnoses and deaths within 24 hours.


A number of family members told the Democrat and Chronicle they've had no word from the company since Cuomo's order went into effect.


"To this date, never have we ever been notified again about anybody being positive or dying," said Jeannie Wells, whose mother moved into The Hurlbut in early March for what was supposed to be short-term rehabilitation stay.


But Hurlbut Care Communities said it had been "working on a system for automated updates, as well as updates to our website for family members."


A list on the Hurlbut web site Sunday said that as of April 25, there had been just six COVID-19 deaths at The Hurlbut, two at Avon and two at Hornell Gardens.


The site indicated there had been coronoavirus infections, but no deaths as of April 25, at the Brightonian on Elmwood Avenue and Shore Winds on Beach Avenue in Charlotte.


One relative said Hurlbut informed her Friday it was publishing a daily update of coronavirus cases diagnosed in the company's 13 New York state nursing homes, but by Sunday the daily update had disappeared from the company's website.


'Die alone'


Among new accounts alleging lack of communication at The Hurlbut are three that tell largely the same story: That nursing home staff disclosed little about the residents' health but took steps to keep them from being transferred to a hospital.


In each case, the resident died of COVID-19 with little warning, their families say.


On Wednesday, April 8, Saundra Peckham complained of stomach distress. The next day she was drowsy and quiet. The day after that, her daughter, Shelly Simmons, couldn’t get her on the phone at all.


Peckman, who was 85, remained incommunicado that weekend. Staff reported she was sleeping and they were checking her vitals every four hours.


“Now I am frantic, upset, concerned and stressed worrying that she may have the virus," Simmons said.


On Monday, April 13, Simmons got two Hurlbut managers on the phone. She asked directly if her mother had COVID-19 and was told they weren’t sure. She asked that her mother be tested and was told "we don’t do things like that." She asked that her mother be taken to the hospital and was told that her mother didn’t want to go.


"The (manager) said she told my mother that if she goes to the hospital she would be put on a ventilator and would die alone. If she were to stay at Hurlbut she would have someone with her," Simmons related.


Simmons said she was shocked. "I said 'How can she be incoherent all weekend long, sleeping, and yet you can have a conversation with her and she’s coherent enough to say 'I don’t want to go to the hospital?'


"How can that happen?"


As the conversation ended, the Hurlbut manager told Simmons they would give Peckham morphine to "make her more comfortable."


She died three hours later. The funeral director told the family later that the nursing home ascribed her death to COVID-19.


"Losing a parent is hard by any means but not having access or information about what is going on intensifies this," she said. "I'm glad there is an investigation because this situation must not be allowed to continue."


Patricia Taliento said a similar thing happened with her 77-year-old brother, Clyde Taliento, a Hurlbut resident who acquired the coronavirus by unknown means in late March and tested postive on March 30.


He developed a high fever but continued to share a room with another resident for four days before being moved into isolation.


Two days after that, on April 4, a staff member called a relative and said Taliento was being taken to a hospital, his sister related.


Shortly after that, a staff member called back to say that Taliento had been warned he would die if he didn’t go to hospital, but had changed his mind and would remain in the nursing home.


He died two hours later, Patricia Taliento said.


She remains angry that her brother, who was not able to leave his room under his own power, had nonetheless become infected. “The virus was brought in to him,” she said.


Comfort care?


Theresa Mitrano had been a resident of The Hurlbut since September 2018, and had lived in other elder-care facilities before that. At 92, she suffered from severe dementia, but was "happy and sweet" and otherwise healthy.


She died at the nursing home on April 9 amid circumstances that continue to anger her niece, Judy DiMartino, who helped direct her aunt’s care.


"We tried so hard for 12 years to keep everything perfect for her, and then somebody lies to you," DiMartino said. "It’s weird. I want to get to the bottom of it."


On April 5, DiMartino had made a routine call to The Hurlbut to check on Mitrano. "They said 'Everything’s fine, she's still herself, she’s okay,'" DiMartino recalled.


Three days later, she received an unsettling call from a staff member at the Hurlbut who was recommending she update her aunt’s care plan.


The care plan, which families prepare when a loved one enters a nursing home, stipulated that Mitrano be taken to hospital if she fell seriously ill. The staffer suggested it might be better for Mitrano to opt only for comfort care at the nursing home in such situations.


"She said they would still take care of her, they would still feed her. It’s just if she became uncomfortable, they'll just give her morphine, rather than take her to the hospital," DiMartino said.


"I said ‘What are you tell me, is she getting worse?' She said 'No, no, no, we’re just doing this with all our residents because of what’s going on here, and because of the advanced age of your aunt."


DiMartino took that as a reference to Rochester’s COVID-19 outbreak. "I said 'Are there any cases of coronavirus there?' There was a hesitation and she said 'We have a few.'"


DiMartino, who held her aunt’s health-care proxy, agreed to change her care plan.


At 5:30 the next morning, a call from Hurlbut woke DiMartino from a sound sleep. Her aunt was dead.


"I was shocked. I said, 'My God, you told me she was fine.' I specifically asked if she was getting worse. Less than 14 hours later, she was gone.


"They told me she died peacefully, she died in her sleep. They made no mention of COVID," DiMartino said.


But the funeral director who handled Mitrano’s arrangements reported that The Hurtbut had informed him Mitrano died of COVID-19, which DiMartino said was later verified by her death certificate.


In fact, the funeral director told the family more than a dozen people had died of COVID-19 there.


Several days later, the Democrat and Chronicle published the first of several stories that highlighted COVID-19 cases at The Hurlbut.


"I said to myself, 'Something’s not adding up,'" DiMartino said. She called the nursing home again.


A staff member agreed to retrieve Mitrano’s care records and read them to DiMartino. What the records revealed shocked DiMartino anew.


Her aunt had been sampled for coronavirus without her niece's knowledge, the records indicated, and the test had come back positive on April 7. The care record contained a notation that staff had called DiMartino that morning and left a voice-mail message informing her that her aunt had COVID-19.


DiMartino is adamant that never happened.


"The chart said they left a message. I had no message," she said. "I will go to the ends defending that they didn’t call me."


She pointed out that the very next day, she called the nursing home and was told Mitrano was fine. That was the day her aunt’s care plan was changed.


DiMartino wants to know why the nursing home urged that the plan be changed, and wants to know why the staff withheld the fact that her aunt had COVID-19.


"I’m not blaming anybody for her getting it. Things are the way they are,” she said. “My point is, if you’re lying to me about her having it, what else are you covering up over there?


"All I want to know is the truth."